It’s estimated a sexual assault occurs in the United States every 107 seconds,1 with 1:6 of the victims being women and 1:33 victims being men.2 For every 100 sexual assaults, there are only 32 that lead to police reports. Of those reports, there are only two felony convictions with as few as two rapists spending just a single day in prison.3 (See Figure 1.)
The long-term effects of sexual assault include high rates of depression and post-traumatic stress disorder. Rape victims are also 13 times more likely to abuse alcohol and four times more likely to contemplate suicide.2 Emotional recovery and cooperation with the judicial process are vastly improved when positive social services and emotional support are provided as early as possible following the traumatic event.4
Several months ago, I was told by a rape crisis counselor that, “A lot of rape cases are lost because of EMTs.” I followed up with her for clarification, and her response was very poignant: EMS providers work well at addressing the patient’s medical needs, but often fail to comprehend or meet a patient’s emotional needs, causing a withdrawal of cooperation from within the judicial process. EMS education also leaves large gaps in knowledge needed to help preserve biological evidence and maintain the chain of custody of evidence taken into our possession. EMS providers are often one of the first people to contact a victim, and their actions play an important role, whether or not an immediate life threat is present.
EMOTIONAL FIRST AID
Sexual assault is a violent act to humiliate, terrorize and degrade the victim, with survivors feeling fear of rejection, humiliation, shame and degradation as part of a host of emotions they experience. Fear of being judged or being seen as liars are two prevalent reasons for not assisting in the judicial process.4 For many male victims, the shame and secrecy is compounded by the fear that their own sexuality may have something to do with being targeted, or at least that others will think so.5 A sexual assault patient will need frequent reassurance that their privacy and confidentiality will be protected.
Figure 1: Statistics for every 100 rapes3
Victims may fear interrogation and forensic physical examination. Patients must always be informed of their right to decline any forensics evaluations and made aware that their consent will be requested each step of the way. Initial cooperation doesn’t prevent patients from changing their mind at any moment or from opting out of part or all of the investigation.
Victims who are unable to consent due to age or cognitive ability are sometimes unaware they were sexually assaulted. Impairment from the use of alcohol or drug precludes consent.
Intoxicated victims may have no recollection of the sexual assault, but may have an unexplained loss of time, or may note evidence such as soiling of clothing, injuries or discomfort, all suggestive of sexual assault. These victims often require greater reassurance that the assault wasn’t their fault.
Self-blame and desire to protect the attacker are common, particularly when the attacker is known to the victim, and especially in cases of domestic violence and sexual abuse. In about 4 of 5 of all sexual assaults, the victim knows the perpetrator.6 There are many agencies available to help victims of domestic violence and sexual abuse. Positive, supportive interactions can empower the victim to accept assistance and begin rebuilding their life.
Victims often have deep fear caused by coercion and threats of retaliation if the crime is reported. Some victims may fear punishment for partaking in illegal behaviors when the sexual assault occurred.7 For example, one victim was so violently attacked that she jumped from a second story window to save her own life. She was initially reluctant to press charges because she had agreed to meet her attacker to share illicit drugs.
Prostitution and the use of illicit drugs make individuals more susceptible to violence, but those behaviors don’t make it legal or morally acceptable to victimize another human being. The victim is in great need of emotional support, and very fragile to judgment.
Finally, victims may be concerned about medical costs and may not be aware that sexual assault victims are eligible for financial reimbursements in most states to cover most related expenses.7
Minimize the number of EMS providers entering the scene, and ideally, enter escorted by a police officer. Avoid touching or disturbing any objects. If you must move an object, report the move to the police and document exactly where it was and where the object was moved. Don’t walk through other footprints, tire marks or blood stains. If you inadvertently disturb a blood spill or spatter on floors, walls and other surfaces, document what occurred and notify one of the police investigators.
Also inform police investigators if blood is spilled while starting an IV or performing other invasive care. Blood left behind due to medical procedures can confuse the evidence.
Victims should be discouraged from engaging in activities that can destroy evidence, such as urinating, defecating, vomiting, douching, removing or inserting a tampon, wiping the genital area or other contaminated body areas, bathing, showering, gargling, brushing teeth, smoking, eating, drinking, chewing gum, changing clothes or taking medications.
Remember, if the patient insists they must, the patient retains their rights. EMS providers should inform patients that they may damage evidence, but the final choice is the patient’s.
When cutting clothes, stay at least six inches away from holes, tears and soiled areas. Avoid excessive handling of articles that contain body fluids. Retain all equipment and supplies used in the treatment of your patient including bandages, sheets and body fluids such as emesis or tissues that may contain mucous. All body fluids can provide potential forensic evidence. If police are on scene, the evidence should be immediately put in police custody. When police aren’t available, which may occur during transport to the hospital, police should be notified as soon as possible that EMS has evidence to be transferred. When a patient is critically injured, it’s likely that clothing will be removed enroute. It may be possible to have an investigator ride onboard to handle evidence collection if it won’t delay transport.
Each article of evidence should be bagged separately to avoid cross-contamination. Commercially prepared wet biological evidence bags are ideal for this purpose, but presently not stocked on most ambulances.9
WHAT To Say
Here are six suggestions for opening a rapport offered by the Rape, Abuse, and Incest National Network, and adapted for EMS providers.8
“I’m sorry this happened.” Acknowledge their experience and express empathy. Say things like, “This must be really tough for you.”
“It’s not your fault.” Reassure your patient they aren’t to blame, and that you won’t judge them.
“I believe you.” Don’t use words like “alleged” or “supposed.” While the accused has the right to remain innocent until proven guilty, the victim has a right and emotional need to be believed.
“I’m here to listen.” Be an attentive listener, but also be comfortable with periods of silence.
“You can trust me.” Reassure them you won’t judge and you’ll protect their privacy and confidentiality. Keep that promise.
“Can we take you to the hospital?” Medical attention is always needed, even if the assault happened a while ago. Your patient may not be aware there are designated facilities that are prepared to meet their needs. Offer to transport them to an appropriate facility or direct them to information and resources.
A victim of sexual assault has experienced a traumatic event that took away their control of their own body. Offering the patient choices gives back control. Even simple questions like, “Would you be more comfortable with a pillow?” or, “Can I get you another blanket?” can be beneficial. EMS providers must request consent before medical evaluation and treatment. This isn’t only legally required, but also vital for the patient’s well-being. Evidence collection and transfer of evidence to police may also require consent. In most states, EMS providers are to report suspected cases of child sexual abuse.
Your patient will have to repeat their story many times. You should only ask pertinent questions related to their emergency medical care, but should the patient choose to share their story with you, listen carefully. Be certain to document patient statements as accurately as possible using quotations whenever applicable. You may later be asked to serve as a witness, and your memory and the victim’s are freshest at the immediate point in time.
Cloth bags, such as pillow cases, shouldn’t be used because fibers from the cloth can cause cross-contamination of the evidence. Paper bags aren’t appropriate for wet biological evidence, as evidence can be damaged or lost when the bag breaks down due to water damage. Wet biological evidence bags used in the field are typically made of Tyvek, which is a strong but breathable plastic. Plastic biohazard bags are acceptable for short-term transportation of wet biological evidence until it can be dried and transferred to a more appropriate evidence bag at a forensic lab.
Evidence must be protected from temperature extremes and from direct sunlight. Don’t leave evidence unattended and unsecured; never leave evidence in a hot vehicle, where moisture and mold are promoted more quickly and can alter biological evidence.9
Proper labeling and handling of the biohazard bag can prevent it from being accidently disposed and will protect the chain of custody. Bags used for evidence must be of ample size to allow for a complete seal. Evidence must be fully sealed with tape to prevent tampering, and the seal must be signed. Collection and bagging of evidence should be witnessed.
Keep all evidence in your custody until properly transferred to a police investigator with thorough documentation of the chain of custody.
You must label each item with a description of what was taken into custody, who secured it, the date and time the item was collected, who controlled the package, whom it was transferred to, and the date and time of transfer. Commercial evidence bags have a label to be completed and signed, making the chain of evidence easier to document thoroughly.
DOCUMENTATION & TRANSPORT
Document injuries with great detail and accuracy, and double-check to make certain there are no errors. Right/left errors are common; be sure to document injuries in reference to the patient’s right or left side. Details should include the location of soft tissue injuries, size, shape, and type of injury such as abrasion, laceration or incision. The patient’s report may be subpoenaed for court, and inaccuracies can be damaging. Also, be certain to document thoroughly to avoid having to rely on memory later on. Because rape is a legal definition, documentation should use the term “reported sexual assault.” Never use terms like “alleged” or “supposed” in documentation of a sexual assault. In court, those statements can be used to imply that even the responders didn’t believe the victim’s story. If the term “rape” is used in a patient report, it should be in the context of a quote and written within quotation marks.
Victim-focused programs have been established to ensure timely, appropriate, sensitive and respectful care, and to facilitate multiagency collaboration. These programs have proven to minimize physical and psychological trauma to the victim, increase reporting, improve quality of evidence collection, and decreased waiting time for victims to be examined.
Paper bags can be used to store dry items containing biological evidence. Evidence bags must be sealed completely to prevent tampering. CanStockPhoto/showface
Within designated facilities, a sexual assault response team (SART) has protocols and dedicated resources for care of sexual assault victims including specialized equipment to detect and document injuries and evidence, dedicated private exam areas and shower facilities, trained advocates, full-time social workers for follow-up counseling services, and emotional support 24 hours a day, seven days per week. As leaders of the team, sexual assault nurse examiners (SANEs) and sexual assault forensic examiners (SAFEs) have extensive training to prepare them to meet sexual assault patients’ needs and to collect forensic evidence.
Sexual assault victims who don’t require immediate emergency medical care should still be offered compassionate and confidential transport, since evaluation and follow-up care are always recommended and the psychological needs of the patient can too easily be underestimated. If the patient refuses non-emergency ambulance transportation, they should be encouraged to immediately go to an appropriate ED, rape crisis center or other designated facility for evidentiary examination to collect physical evidence and for crisis counseling.
Victims of sexual assault are most often the only people who can identify the sex offender, and they need to trust they’ll be protected physically and emotionally in order to do so.
Our first mission is always to assure safety and find and manage life threats, but never overlook the importance of providing emotional support and preserving evidence of a crime.
A reassuring, supportive and nonjudgmental approach is pivotal to recovery and to prosecution of perpetrators. EMS providers have the power to help assure justice for the survivor, aid in the prevention of future assaults, and possible save countless lives indirectly.
Acknowledgment: The author would like to thank collaborator Karen Beckman, RN, MSN/Ed, SANE-A, for her help with this article.
- American College of Emergency Physicians. Evaluation and management of the sexually assaulted or sexually abused patient, 2nd edition. ACEP: Dallas, Texas, 2013.
- Asaeda G, Braun J, Prezant D. Keeping patients SAFE: New York City providers respond to sexual assault victims. JEMS. 2001;36(8):52–53.
- Beckman K: Domestic violence and sexual assault. In Beebe R (Ed.), Professional paramedic, volume II: Medical emergencies, maternal health and pediatrics, 1st edition. Delmar, Cengage Learning: Clifton Park, N.Y., pp. 916–926, 2011.
- Behar J. (n.d.) Emergency medical services protocol for sexual assault. Ohio.gov. Retrieved Feb. 3, 2015, fromwww.healthy.ohio.gov/sadv/sassault/~/media/211A5115C7BE49D99029A92199B29347.ashx.
- Chen O, Steer S. (2012.) Emergency medical services protocol for sexual assault. Ohio.gov. Retrieved Feb. 3, 2015, fromwww.healthy.ohio.gov/~/media/HealthyOhio/ASSETS/Files/SADVP/Ohio%20Protocol/Appendix%2017%20revised%202013.ashx.
- FBI. (Dec. 11, 2014.) Frequently asked questions about the change in the UCR definition of rape. Retrieved June 7, 2015, from www.fbi.gov/about-us/cjis/ucr/recent-program-updates/new-rape-definition-frequently-asked-questions.
- Futrelle J. (May 23, 2009.) EMS response to sexual assault. The EMT Spot. Retrieved Feb. 16, 2015, fromwww.theemtspot.com/2009/05/23/ems-response-to-sexual-assault/.
- New York State Department of Health. (March 2007.) Sexual assault forensic examiner program. Retrieved Feb. 17, 2015, fromwww.health.ny.gov/professionals/safe/.
- The U.S. Department of Justice. (n.d.) Raising awareness about sexual abuse: Facts and statistics. Retrieved June 22, 2015, fromwww.nsopw.gov/en/Education/FactsStatistics?Aspx.
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5. Kulikowski A. (March 26, 2013.) Common victim behaviors of victims of sexual abuse. Pennsylvania Coalition Against Rape. Retrieved Aug. 10, 2015, from www.pcar.org/blog/common-victim-behaviors-victims-sexual-abuse.
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